Based on record reviews and staff interviews the facility failed to provide adequate staffing to provide care on [DATE]. The evening of [DATE] Nurse #1 worked from 7:33 PM until 11:00 PM and was the only licensed nurse to provide resident care and services for 71 residents in the facility. Nurse #1 did not know where to locate transfer paperwork for Resident #1 and as a result he was not sent to the hospital until hours after the facility was notified of an elevated troponin level (a heart enzyme that can indicate heart damage). Nurse #1 was not aware she was the only nurse in the facility until approximately 8:30 PM when Nurse Aide #1 communicated this to her and informed her a resident on the [NAME] unit had requested an as needed medication. …
F725 citations in North Carolina
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F725 less often than its own record predicts
0.43 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F725 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review, observations, staff and provider interviews, the facility failed to ensure adequate staffing to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer and were able to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth.Cross refer to F686 Based on record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. …
Based on record review, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to ensure there was sufficient nursing staff in the facility on 5/16/26 from 1:00 PM to 5:00 PM to administer medications as ordered to the D and E halls for 6 of 32 residents reviewed for medication administration (Resident's #4, #5, #6, #7, #8 and #9).The findings included: This tag is cross referenced to: F658: Based on record reviews, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration. (Residents ##4, #5, #6, #7, #8 and #9). …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.67% | 0.84× |
| 2024 | 0.44% | 0.55× |
| 2025 | 0.34% | 0.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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